For discussion and debate about the ethics of health care organizations and the wider health system.

Sunday, August 1, 2010

WikiLeaks and Medical Ethics

WikiLeaks, the secure website that publishes documents leaked by whistleblowers, has been front page news since it published 92,000 secret Pentagon documents from Afghanistan. Its founder - Julian Assange - is a fascinating person. He, and the WikiLeaks venture, have a lot to teach about organizational ethics. (My information and quotes come from a terrific New Yorker article about Assange by Raffi Khatchadourian.)

My goal for this blog (and for much of my work) is the same as Assange's - to improve the ethical performance of organizations and public agencies. But our world views and methodologies are so different that I fear Assange would describe me as he described physicists at a conference he attended - "sniveling fearful conformists of woefully, woefully inferior character."

I operate from the quality improvement perspective - the belief that most people in health care want to do the right thing, but may be impeded by faulty systems, which include intellectual/ethical constructs as well as production processes. My methodology is analysis, teaching, and advocacy.

Assange's world view is much darker. Here's how Khachadourian describes it:

He [came] to understand the defining human struggle not as left versus right, or faith versus reason, but as individual versus institution. As a student of Kafka, Koestler, and Solzhenitsyn, he believed that truth, creativity, love, and compassion are corrupted by institutional hierarchies, and by “patronage networks”—one of his favorite expressions—that contort the human spirit. He sketched out a manifesto of sorts, titled “Conspiracy as Governance,” which sought to apply graph theory to politics. Assange wrote that illegitimate governance was by definition conspiratorial—the product of functionaries in “collaborative secrecy, working to the detriment of a population.” He argued that, when a regime’s lines of internal communication are disrupted, the information flow among conspirators must dwindle, and that, as the flow approaches zero, the conspiracy dissolves. Leaks were an instrument of information warfare.

Assange learned this outlook early. His mother "believed that formal education would inculcate an unhealthy respect for authority in her children and dampen their will to learn." She told Khatchadourian "I didn't want their spirits broken." When Assange was eleven his mother separated from his stepfather, who she feared was part of a dangerous cult. "Assange recalled her saying, 'Now we need to disappear,' and he lived on the run with her from the age of eleven to sixteen." By the time Assange was fourteen they had moved thirty-seven times.

Assange's mission is to expose injustice, and injustice is everywhere. Because he sees injustice and exploitation as the basic truth about the world, the default position for organizations and governments, he rejects the Hippocratic injunction to "first, do no harm." His precept is "first, fight tyranny!"

His mission is to expose injustice, not to provide an even-handed record of events. In an invitation to potential collaborators in 2006, he wrote, "Our primary targets are those highly oppressive regimes in China, Russia and Central Eurasia, but we also expect to be of assistance to those in the West who wish to reveal illegal or immoral behavior in their own governments and corporations." He has argued that a "social movement" to expose secrets could "bring down many administrations that rely on concealing reality—including the US administration."

Assange does not recognize the limits that traditional publishers do. Recently, he posted military documents that included the Social Security numbers of soldiers, and in the Bunker I asked him if WikiLeaks’ mission would have been compromised if he had redacted these small bits. He said that some leaks risked harming innocent people—"collateral damage, if you will"—but that he could not weigh the importance of every detail in every document. Perhaps the Social Security numbers would one day be important to researchers investigating wrongdoing, he said; by releasing the information he would allow judgment to occur in the open.

To those for whom harm perpetrated against individuals by government and large organizations is the default expectation, primum non nocere is Pollyanna foolishness.

Assange's ethic is that of public health, not clinical medicine. His passion is for social justice, and in pursuing that aim, individuals will inevitably be injured.

Societies need ferocious warriors for justice like Assange, but his stance of constant vigilance and deep suspiciousness come at a high cost - isolation, fear, and vulnerability to despair. Societies also need gentler leaders who expect imperfection, meet individuals and organizations where they are, and ask them to become better, more in tune with their ideals.

2 comments:

I definitely understand those who take the in-your-face approach to pursuing change, but when it comes down to it, that kind of attack just puts people on the defensive. It takes a lighter touch to affect real change, even though it can be frustrating at times.

Thanks for your comment. My temperament is definitely in accord with your view. The in-your-face approach doesn't come naturally to me. The lighter touch does. But I think there are situations that call for the kind of nuclear approach Assange takes.

Ralph Nader is an important example of the pluses and minuses of the in-your-face approach. He did a tremendous amount of good for automobile safety and other consumer issues. But his rigid perfectionism led him to run for president in 2000 and claim there was no difference between Bush and Gore. He probably cost Gore the election, which means he's partly responsible for the Iraq fiasco and so much more.

About Me

I've been in health care for 50 years -- as psychiatrist, medical director, teacher/researcher, consultant, leader of the ethics program at a not-for-profit health plan, and patient. I'm a clinical professor in the departments of Population Medicine and Psychiatry at Harvard Medical School. With colleagues I've written two books about health system ethics: "Setting Limits Fairly: Learning to Share Resources for Health," and "No Margin, No Mission: Health-Care Organizations and the Quest for Ethical Excellence." I've had my Medicare card since 2004.

About the blog

Medical ethics has traditionally focused on the individual patient, the individual doctor, and the patient-doctor relationship. But today most care occurs in organizational settings – group practices, HMOs and ACOs, VA and more. Insurers and other third parties have a huge influence on the exam room. Medicare shapes care for the elderly and disabled. Medicaid does the same for the poor. Hospital cultures and policies affect what sick patients experience, for both better and worse.

All this means that the ethical quality of health care is profoundly influenced by the ethics of organizations. We can’t have ethical health care without ethical organizations.

In the blog I discuss how organizations engage with the ethical dimensions of their work. I look for approaches we can learn from, not simply to wring my hands and rant. I hope the blog stimulates discussion and debate, and encourage readers to present their own perspectives and suggest topics for postings. Although organizational ethics is my main focus, I also write about other ethical issues that interest me.